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Complex > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

what is ventilation

A

the movement of air btw atmosphere and the alveoli-by inhalation/exhalation, higher to lower pressure

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2
Q

minute ventilation

A

volume inhaled/exhaled per minute = 7500ml at rest

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3
Q

alveolar ventilation

A

volume of fresh gas entering respiratory zone available for gas exchange per minute

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4
Q

if rapid breathing, how are PaCO2 and alveolar ventilation impacted

A

alveolar vent is increased and CO2 decreases

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5
Q

diffusion

A

exchange of O2 and CO2 b/w pulmonary capillaries and the alveoli

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6
Q

what impacts diffusion (4)

A
  1. Affected by surface area available for diffusion
  2. Affected by thickness of alveolar-cap membrane
  3. partial pressure of gas across the membrane
  4. and solubility and molecuar characteristics of the gas
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7
Q

perfusion

A

flow of blood through the pulmonary capillary bed

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8
Q

what is transport

A

Oxygen and co2 being circulated in the blood and to and from the cells

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9
Q

how is o2 transported

A

RBCs - hemoglobin (97%)
Dissolved in blood (3%)

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10
Q

how is co2 transported

A

Dissolved in blood (10%)
Attached to hemoglobin (30%)
Bicarbonate in bloodstream (60%)

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11
Q

What drugs can go down ET tube because they are metabolized in lung tissue?

A

Lidocaine
Epi
NARCAN
Atropine

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12
Q

conducting airways

A

No actual gas exchange takes place here (anatomic dead space)
Nasopharynx warms, humidifies and filters air
Includes naso and oropharynx, trachea, bronchi, bronchioles, and terminal bronchioles

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13
Q

respiratory airways

A

Respiratory bronchioles, alveolar ducts, and alveolar sacs
Surrounded by smooth muscle

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14
Q

type 1 alveolar cells

A

responsible for gas exchange

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15
Q

type 2 alveolar cells

A

secrete surfactant
Macrophages present to remove foreign substances

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16
Q

what is the v/q relationship

A

Ventilation/perfusion (V/Q) relationship
Measure of how well someone is ventilating vs perfusing

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17
Q

what is the normal v/q

A

Normal is 0.8 - 1 (4L/minute of ventilation to 5L / minute of perfusion)

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18
Q

what 5 things influence V/Q

A
  1. anatomical dead space
  2. alveolar dead space
  3. anatomical shunt
  4. physiological shunt
  5. silent unit
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19
Q

anatomical dead space

A

Conducting airways
*Tubing from ET tube back to ventilator - adds dead space

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20
Q

High V/Q ratio (alveolar dead space)

A

-Normal or good ventilation with decreased or no perfusion
-When regions in respiratory airways are ventilated but not perfused
-ex: pulmonary embolism, cardiogenic shock (amount of o2 in alveoli is so low)

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21
Q

shunt

A

blood bypasses alveoli w/o picking up O2

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22
Q

anatomical shunt

A

Patent ductus arteriosus
ASD
VSD
Patent foramen ovale
Mixing of oxygenated and deoxygenated blood → dilutes oxygen to tissue

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23
Q

physiological shunt (low VQ)

A

low ventilation, normal perfusion
decreased gas exchange
d/t obstruction like a mucus plug in the tube

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24
Q

physiological shunt (high VQ)

A

High VQ (good ventilation) but poor perfusion = alveolar dead space
I.e. PE, cardiogenic shock

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25
Q

silent unit

A

low / no perfusion and low/no ventilation
(ex: pneumothorax, patient with ARDs)

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26
Q

normal PaO2: FiO2

A

normal > 300

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27
Q

what does a PaO2: FiO2 of 200-300 mean

A

one of the mismatches is happening → 15 - 20% shunting

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28
Q

what does a PaO2:FiO2 of 100 mean?

A

100 > 20 % shunting

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29
Q

four cardinal symptoms of respiratory distress

A

Dyspnea
Chest pain
Sputum production
Cough

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30
Q

crackles

A

rales - high pitched brief popping sound heard during inspiration
Fluid in smaller airways / alveoli trying to open and not opening or terminal airways that are collapsed
Classic in CHF, pneumonia
Sounds like hair being rubbed together

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31
Q

rhonchi

A

Deep low pitched rumbling
Snore, gurgle
Can be expectorated
Noise comes from sputum in airways
Bronchitis, pneumonia

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32
Q

wheeze

A

Asthma, COPD
High pitched

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33
Q

friction rub

A

Same as pericardial rub
Usually heard on inspiration
Two surfaces with fluid are rubbing together
Sounds like sandpaper
Hear in heart beat - pericardial effusion
Cardiac or respiratory?
Would go with rate - either HR or RR

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34
Q

stridor

A

High pitched inspiratory sound
Crowing
When we have air passing through constricted trachea
Constriction, obstruction
Medical emergency
Need to be intubated or intubated
Croup in pediatrics

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35
Q

3 goals of O2 therapy

A

Correct hypoxemia
Decrease work of breathing
Decrease myocardial workload

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36
Q

if you patient has a problem with oxygenation, what do they need

A

more FiO2

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37
Q

if your patient has a problem with ventilation, what do they need

A

more flow (bipap, cpap or additional breaths)

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38
Q

what is effective O2 therapy

A

lowest FiO2 and lowest amount of oxygen - to achieve normal SaO2 or normal PaO2 on pulse ox

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39
Q

6 factors affecting success of supplemental O2

A

medical history
LOC
patent airway
RR
depth of breathing (tidal volume)
hgb level

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40
Q

5 complications of supplemental o2

A

Skin breakdown
Drying of mucous membranes
Epistaxis
Infection of the sinuses
Oxygen toxicity

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41
Q

who can get CPAP

A

Can only be used on patients breathing spontaneously - just o2 issues, not ventilation issues

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42
Q

5As for treating smoking use and dependence

A

Ask about tobacco use - at every visit
Advise to quit
Assess willingness to make attempt to quit
Assist in attempt at quitting - offer medication, provide counseling or referral
Arrange follow up

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43
Q

pulmonary function test

A

Measures lungs ability to move air in and out of alveoli

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44
Q

CT scan (PE protocol)

A

Need large bore IV, know kidney functions
Contrast - hold metformin for 48 hours after to avoid lactic acidosis
Check lab results
*Contrast dye is nephrotoxic

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45
Q

what can a chest x ray be used for

A

Sees tubes/drains/catheter placements
Pulmonary edema, pleural effusion
pneumothorax
Can see bones
See infiltrates
Cardiomegaly → muscle has gotten thicker/hypertrophied → means EF is low

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46
Q

bronchoscopy

A

direct visualization of tracheobronchial tree/larynx
Can remove foreign objects
Can do biopsies
Can stop bleeding
Can be done while patient is ventilated

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47
Q

thoracentesis

A

Can remove fluid during pleural effusion → decreased surface area for o2 and co2 exchange → SOB, DOE
Can be diagnostic or therapeutic
Therapeutic = symptom mgmt
Diagnostic - send drainage to lab and get diagnosis - (i.e. WBC, cancer cells, etc)

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48
Q

end tidal co2 monitoring

A

Measures maximal partial pressure of CO2 obtained at the end of an exhaled breath

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49
Q

capnography

A

continuously monitors the PaCO2 in the airway during inhalation and exhalation and provides a written tracing

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50
Q

normal paCO2 values

A

35-45 mmhg

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51
Q

normal HCO3 - values

A

22-26 meq/l

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52
Q

normal PaO2

A

80-100 mm hg

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53
Q

what is an anion gap and what is the normal level

A

specialized blood tests that lets us know about metabolic acidosis
Look at difference b/w sodium + potassium on one side and Cl and HCO3 on the other
Less than 12 = normal

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54
Q

BNP

A

Want to know if someone has pulmonary edema d/t HF → will impact oxygenation
Increases as HF worsens

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55
Q

normal BNP level

A

less than 100

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56
Q

BNP of 100-300

A

mild volume overload of some kind

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57
Q

BNP of over 600

A

moderate HF, pulmonary edema

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58
Q

BNP of over 1000

A

severe pulmonary edema

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59
Q

BNP over 5000

A

kidney problems

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60
Q

D Dimer and normal level

A

indicates Degradation of certain fibrin molecules in the blood
Normal = less than 0.50

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61
Q

what meds are important with COPD exacerbation (4)

A

Bronchodilators, mucolytics, corticosteroids, oxygen

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62
Q

what meds are important with pulmonary edema?

A

diuretics, oxygen

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63
Q

which med is most important with CHF or pulmonary edema

A

diuretics

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64
Q

how to get ABG sampling

A

-Radial, brachial or femoral site (no tourniquet needed)
-Wipe with chlorhexidine, 20G needle, heparinized syringes, insert 30 - 45 degrees with bevel up right below where you feel the pulse → 3-5ml → hold pressure for 3-5 minutes on artery → put sample it on ice and to the lab (ice to reduce oxygen metabolism and give more accurate reading)

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65
Q

allen’s test

A

if using radial approach for ABG sampling
Testing patency of other vessel supplying hand - ulnar artery
Positive test = ulnar is patent

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66
Q

uncompensated ABGs

A

ph and 1 PaCO2 OR HCO3- are going to be abnormal

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67
Q

partially compensated ABGs

A

ph is still abnormal and both PaCO2 and HCO3 are abnormal

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68
Q

fully compensated ABGs

A

ph is normal but PaCO2 and HCO3 are not normal

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69
Q

indication for chest tubes

A

To drain fluid or air from the thoracic cavity, in the pleural space
-Hemothorax
-Pneumothorax
-Tension pneumothorax
-Pleural effusion

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70
Q

hemothorax

A

Blood collects b/w chest wall and lungs in pleural cavity
Can cause lung to collapse if volume buildup is so high

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71
Q

s/s of hemothorax (4)

A

Chest pain
Difficulty breathing
Reduced breath sounds on affected side
Rapid heart rate

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72
Q

pneumothorax

A

Air leaks into space b/w lung and chest wall

can be closed, open or tension

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73
Q

tension pneumothorax

A

air in pleural space increasing and unable to escape
Pressure is so great that lung pushes up and becomes non functioning
Everything is pushed (trachea, heart) to unaffected side
Breath sounds will be absent on affected side

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74
Q

tx for tension pneumothorax

A

needle decompression w/ large bore needle into 2nd intercostal space in midclavicular line

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75
Q

pleural effusion

A

Fluid between pleural space, 2 pleural linings

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76
Q

s/s of pleural effusion

A

SOB,
chest pain especially when breathing in deeply,
activity intolerance,
DOE,
cough

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77
Q

tx for pleural effusion

A

drained with thoracentesis or chest tube

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78
Q

3 chambers of drainage systems for chest tubes

A

Collection
Water seal chamber
Suction apparatus

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79
Q

what is normal finding in drainage system

A

Tidaling - normal finding subtle up and down of water in under water seal chamber (usually middle chamber)

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80
Q

normal finding in chest tube drainage system for spontaneous breathers

A

Should rise a little with inspiration because you are getting more negative
Should fall during expiration when patient is breathing spontaneously

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81
Q

normal finding in chest tube drainage system for mechanical ventilation

A

Fall during inspiration because you are putting positive pressure into lungs
Should rise during expiration when positive pressure is pumped out

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82
Q

how often do you check VS and CV/pulm for patient with chest tube

A

q2

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83
Q

how often do you mark and monitor drainage for chest tubes

A

q15, q 30, q1, q4,q8

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84
Q

what does a sudden increase in drainage mean?

A

could be internal bleeding
More than 150-200 ml when its been going down → need to let someone know

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85
Q

what does it mean if the chest tubes suddenly stop draining

A

expect its a clot
assess for air leaks and that connections are sealed

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86
Q

how will patient breathe with chest tube

A

they’ll be in pain so more shallow breathing –> can lead to atelectasis
pt should splint with pillow towel and be medicated

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87
Q

subq emphysema

A

When you palpate - feels like rice krispies = air is escaping from lungs
Happens if chest tube moves → air will escape into sub q tissue
Looks like edema
Long time to reabsorb back in

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88
Q

what is another complication of chest tubes

A

tension pneumo

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89
Q

what do you do if there is a dislodgement or accidental removal of chest tube

A

Petroleum gauze with DSD and occlusive tape: occludes the opening

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90
Q

paO2

A

Measures oxygen levels in arterial blood
No acid base role
Indicates hypoxemia when low

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91
Q

SaO2

A

Represents % of hemoglobin molecules that are bound with O2 in arterial blood

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92
Q

normal level of SaO2

A

93-97%

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93
Q

what can cause resp acidosis

A

May be result of inefficient pulmonary function or excessive production of CO2
CNS depression
Decreased ventilation
Pulmonary edema

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94
Q

causes of resp alkalosis (6)

A

Anxiety
Fear
Hypoxia
Pain
Head injury
Mechanical ventilation

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95
Q

causes of metabolic acidosis (4)

A

Diarrhea
GI losses
Renal failure
DKA / ketoacidosis (Ketones are produced when body is forced to use fat to create injury because lack of insulin that is converting glucose to energy
Fat is turned into ketones = acids → accumulate in bloodstream)

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96
Q

causes of metabolic alkalosis (4)

A

Vomiting
Diuretics
High NG output
Antacids

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97
Q

what is the normal amount of drainage in the drainage system

A

typically less than 100 cc/hr

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98
Q

what does excessive bubbling in the air leak monitor mean

A

can mean air leak

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99
Q

what does intermittent bubbling in the air leak monitor mean

A

pt might have pneumothorax (expected)

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100
Q

if chest tube becomes dislodge, what do you do?

A

Sterile dressing
Tape on 3 sides - allows air to escape and prevent pneumo
Notify MD

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101
Q

steps for chest tube removal

A

-Done at bedside by physician
-Gather supplies - sterile gloves, suture removal kit
-Teach valsalva’s maneuver - deep breath, exhale and bear down during removal – prevents air entering pleural space during removal
-Pre-medicate for pain
-Position semi fowler’s
-Monitor respiratory status, lung sounds, drainage, chest rising, dyspnea
-chest x ray to assess lung

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102
Q

6 goals of intubation

A

-Maintain alveolar ventilation appropriate for the patient’s respiratory & metabolic needs
-Correct hypoxemia and maximize oxygen transport
-Protect the airway
-Alleviate respiratory distress
-Prevent or reverse atelectasis
-Acid/base balance

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103
Q

indications for intubation

A

-Brain injury
-Surgeries b/c of general anesthesia
-Airway obstructions
-Non-patent airway d/t trauma
-V/Q mismatch (PE, Pneumothorax)
-Copious amounts of secretions
-Prevention for aspiration and pneumonia
-coma
-change in LOC
-impending cardiac arrest

104
Q

what flow should ambu bag be set at during intubation

A

15 L flow, 100% oxygen

105
Q

nurse’s role pre-intubation (10)

A

-Vitals, O2 sat
-Consent if elective
-Allergies
-Know history
-Labs
-Pre-medications
-Ambu bag - provide oxygen
-Gather equipment
-oxygenate/ventilate the patient
-Suction PRN

106
Q

nurse’s role during intubation

A

-Vitals
-Auscultate breath sounds bilaterally
-Timing procedure → don’t want patient going too long without o2
-Inflate cuff
-Secure tubes
-Bag until vent arrives
-Order CXR
-Note tube placement

107
Q

meds for intubation: neuromuscular blockers or sedation first

A

sedation

108
Q

sedation meds (3)

A

Etomidate
Propofol
Midazolam (Versed)

109
Q

neuromuscular blockers (4)

A

Succinylcholine (agonist)
Vecuronium (antagonist)
Rocuronium
Pancuronium

110
Q

how to confirm placement of intubation

A

-Bilateral breath sounds
-Colormetric CO2 detector - Gold is good
-Misting in the tube
-CXR to confirm placement
-Capnography waveform reading
-End tidal co2

111
Q

cuff management following intubation (pressure number, how often to check, what’s the purpose)

A

To prevent trachea ischemia, fistulas - use low pressure high volume cuff
Don’t want above 20-25 mm Hg pressure
Should check q8h

112
Q

nursing mgmt of tube: suctioning

A

Sterile procedure
In line or catheter
Pre-oxygenate FiO2 100% 3x then suction
Do not suction for more than 15 seconds
No more than 3 passes at a time

113
Q

oxygen/FiO2 mgmt for patients with tube

A

Usually started on 100%
Usually titrated to maintain PaO2 > 60 mmHg (SaO2 > 90 mmHg)

114
Q

when are patients at risk for oxygen toxicity

A

FiO2 60% for more than 24 hours

115
Q

how do you know if you can turn down patients oxygen levels with tube

A

ABGs

116
Q

minute ventilation

A

RR x Tidal Volume –> determines alveolar ventilation

117
Q

what is tidal volume

A

volume of gas (ml) delivered/ moved in/out of lung in a normal inspiration/expiration

118
Q

normal tidal volume

A

5-8 ml/kg

119
Q

what is lung protective tidal volume levels

A

6-8 ml/kg

120
Q

what is PEEP

A

Positive End Expiratory Pressure
Positive pressure delivered at end of expiration to keep alveoli open

121
Q

what level of PEEP is adequate in most patients to maintain SaO2 or PaO2

A

Low pressures (2-5cm H2O)

122
Q

what PEEP pressure do patients with refractory hypoxemia (ARDs) get

A

8-10 cm H2O

123
Q

complications of PEEP

A

-impedes venous return –>
decreases CO and BP
-decreased circulatory flow
-hypotension

124
Q

high pressure alarm

A

indicates increases airway resistance or decreased lung compliance

Decreased lung compliance d/t atelectasis, pneumothorax, pulmonary fibrosis, pulmonary edema

Increased airway resistance d/t bronchospasm, bucking the ventilator, coughing, secretions, biting, kinks, agitation

125
Q

low pressure alarm

A

d/t disconnection

126
Q

what should do if alarm is going off

A

ventilate with Ambu bag until you figure it out

127
Q

ET tube complications

A

-Oral vs. Nasal
-Lip, tongue, teeth, tracheal damage
-Mucous plugs
-Patient bites tube
-Sinusitis
-Fistula
-Granulomas
-Infection- VAP
-Cuff ulceration

128
Q

how to prevent aspiration

A

OG tube
Head elevation > 30
Suction
Cuff pressure - 20-24 mm Hg

129
Q

what does aspiration increase risk of

A

VAP or ARDs

130
Q

barotrauma

A

rupture of alveoli or emphysematous bleb secondary to the increased positive pressure (with ventilation/PEEP) which leads to air tramping in pleural space and development of Tension Pneumothorax = medical emergency!

131
Q

VAP

A

Second most common HAI
Pt who has been intubated for at least 48 hours
Will appear white on CXR

132
Q

nursing prevention measures for VAP

A

Hand washing
Gloves while manipulating or suctioning ETT
VAP bundle
-Oral care q4h
-HOB 30-45 degrees
-GI prophylaxis w/ PPI
-DVT prophylaxis w/ lovenox (40 ml sq daily = preventative)
-OOB
-Alcohol free mouthwash, teeth brushing, frequent oral suctioning

133
Q

what is a bundle

A

Bundle = intervention with 4-6 related interventions - done together decreases issue

134
Q

criteria for weaning

A

Hemodynamically stable
Core temp > 36, < 39
Cxray-no abnormal findings, treat pathology prior
SaO2 > 90% on FiO2 of < 40% and PEEP of 5 or less
ABG and major electrolytes WNL or baseline for patient
No residual paralytics
Hematocrit > 25%
Adequate pain/anxiety/agitation management

135
Q

patient positioning during weaning trials or removal of ET tube

A

reverse trendelenburg and/or semi- to high-Fowler’s position may improve respiratory movements

136
Q

ARDs

A

Considered a complex syndrome
Inflammatory lung injury resulting in HYPOXEMIA
Many different causes but all involve some sort of direct or indirect injury to the lung
*diagnosis of exclusion

137
Q

most common cause of ARDs

A

sepsis

138
Q

Berlin definition ARDs: oxygenation mild

A

200 mg Hg < PaO2/FiO2 <= 300 mm Hg with PEEP or CPAP >= 5cm H2O

139
Q

Berlin definition ARDs: oxygenation moderate

A

100 mm Hg < PaO2/FiO2 <= 200 mm Hg with PEEP >= 5cm H2O

140
Q

Berlin definition ARDs: oxygenation severe

A

PaO2 / FiO2 <= 100 mm Hg w/ PEEP >= 5cm H2O

141
Q

criteria of Systemic inflammatory response syndrome (SIRS)

A

two or more of the below:
Temp > 100.4 F or < 98 F
Heart rate > 90 BPM
Respiratory rate > 20/min or PaCO2 <32 mm Hg
White Blood Cell count >12,000 cells/mm3 or < 4000 cells/mm3 or > 10% immature (band) forms

142
Q

what is SIRS

A

Systemic inflammatory response syndrome
can lead to multisystem organ dysfunction with the respiratory system usually being the first affected

143
Q

what do the stages of ARDS respresent

A

symptom onset progression

144
Q

ARDs stage 1

A

first 24 hours
Subtle sign = tachypnea
-restlessness,
-dyspnea
-moderate to extensive use of accessory muscles
-No changes on xray yet
-ABG may show resp alkalosis

145
Q

ARDs stage 2

A

24-48 hours
s/s: tachypnea, dyspnea on exertion, tachycardia, use accessory muscles, agitated/confused b/c of hypoxia
Coarse bilateral crackles
Decreased air entry into dependent lung fields
CXR: patchy bilateral infiltrates
ABG decreased SaO2 despite supplemental O2

146
Q

ARDs stage 3

A

2-10th day
-Crackles in lungs → white out lungs
-Increased lethargy
-Change in LOC
-O2 sat decreasing, Need more O2
-Increase in arrhythmias, chest pain
-CXR: decrease lung volumes
-Renal system affected - decreased output, edema
-decreased bowel sounds
-ABG: worsening hypoxemia

146
Q

ARDs stage 4

A

after 10 days
-Symptoms of MODS
-CXR: Pneumothoraces pneumos
-Surfactant damaged causing alveolar collapse
-ABG Worsening hypoxemia and hypercapnia (more shunting now)

147
Q

ARDs late symptoms (b/w stages 3-4)

A

need to be intubated, high FiO2 %, high PEEP, diffuse crackles, tachycardic with decreased CO, hypotension, might need vasopressors for BP, might need CCRT to filter blood

148
Q

3 pathophys hallmarks of ARDs:

A

Change in lung vascular tissue
Increase in lung edema
Impaired gas exchange

149
Q

oxygenation goals for ARDs

A

PaO2 of 55-88 mmHG with SaO2 88-95%

150
Q

PaO2: FiO2 ratio goal for ARDs

A

200-300

151
Q

secondary complications of ARDs

A

Ventilator assisted/induced lung injury (VALI/VILI) - Barotrauma, volutrauma
SIRS
Multisystem organ dysfunction (MODS) due to hypoxemia
PE, DVT, atelectasis, and nosocomial infections due to immobility

152
Q

acute respiratory failure

A

Characterized by sudden and life threatening deterioration of gas exchange
Results in CO2 retention (hypercapnia) and/or inadequate oxygenation (hypoxemia)

153
Q

Acute respiratory failure PaO2

A

< 55- 60 mm Hg hypoxemia

154
Q

acute respiratory failure PaCO2

A

> 50 mmHg hypercapnia

155
Q

acute respiratory failure ph

A

< 7.35 severe acidosis

156
Q

two classifcations of acute respiratory failure

A
  1. acute hypoxemic respiratory failure
    2 acute hypercapnic respiratory failrue
157
Q

Acute Hypoxemic Respiratory Failure

A

Defect in oxygenation
PaO2 of < 55-60mmHg

158
Q

acute hypercapnic respiratory failure

A

Defect in ventilation
CO2 > 50mmHg
r/t ventilation side - decreased ventilatory drive (narcotics, alcohol, brainstem lesion, ALS, increased work of breathing d/t COPD exacerbation or asthma)

159
Q

diagnostics for acute respiratory failure

A

ABGs
CXray for opacities to see if it is pulmonary edema

160
Q

nursing mgmt for acute respiratory failure

A

-Airway: intubate and ventilate
-O2: restore and maintain oxygenation - 100% while waiting for intubation
-Correct Acid-Base disturbance with ventilator support
-Restore Fluid/electrolyte balance - might need diuretics
-Optimize cardiac output w/ PA catheter
-Nutritional support
-Treat underlying cause
(I.e. pneumonia → antibiotics
Volume overload → diuretics)

161
Q

if it is determined that acute respiratory failure is a ventilation problem, what do you do

A

ambu bag, narcan, give more breaths, stop sedation

162
Q

if it is determined that acute respiratory failure is a oxygen problem, what do you do

A

give more O2

163
Q

what is the number one answer to increase perfusion

A

IV fluids

164
Q

how to assess perfusion

A

cap refill
> 3 is not good

165
Q

acute respiratory failure goals

A

-Patent airway will be maintained
-Oxygenation will be maintained: PaO2 of 80-100 mmHg with SaO2 > 90%
-ABGs will be within normal limits

166
Q

will hypoventilation increase or decrease ETCO2

A

increase

167
Q

with each cardiac cycle, what % of CO is pumped into kidneys

A

20%
1.2 L/minute

168
Q

what is urea

A

breakdown of protein

169
Q

what is creatinine

A

end product of breakdown of muscle

170
Q

RAAS system

A

Decreased BP d/t dehydration or blood loss → renin released → angiotensinogen converted to Ang I converted to ang II w/ ACE → a2 constricts smooth muscle of arterioles → increased BP → increases GFR

171
Q

how does ADH work

A

chemical produced in the brain that causes the kidneys to release less water, decreasing the amount of urine produced

172
Q

aldosterone

A

secreted when GFR falls and increases Na+ & H2O reabsorption → increases GFR

173
Q

ACE inhibitors

A

Prevents conversion of Angiotensin 1 to angiotensin 2
Stops Na secretion, stops ADH production, stops arteriolar vasoconstriction

174
Q

ARBs

A

Blocks receptors thereby promoting vasodilation, Na and H2O excretion

175
Q

spironoloactone

A

Works in late distal convoluted tubule to prevent reabsorption of Na
Potassium sparing
least amount of diuresis

176
Q

furosemide

A

loop diuretic
Prevent reabsorption of Na and K in ascending loop of henle
*most diuresis

177
Q

HCTZ - hydrochlorothiazide

A

thiazide diuretic
Prevents Na reabsorption in early distal convoluted tubule
first line for HTN

178
Q

how do we measure kidney function

A

GFR

179
Q

GFR

A

Measure of filtration efficiency based on Cr in serum

180
Q

normal GFR

A

> 60

181
Q

if BP is low, how does smooth muscle in kidneys react

A

BP is low - smooth muscle will vasodilate → increase perfusion to keep GFR constant

182
Q

if BP is high, how does smooth muscle in kidneys react

A

If BP is high → smooth muscle will vasoconstriction to decrease perfusion to keep GFR constant

183
Q

renal blood flow path

A

Receives blood from renal artery → branches into afferent arteriole → capillaries / glomerulus → filtration → leaves by efferent arteriole

184
Q

two biggest risk factors for kidney failure

A

HTN and diabetes

185
Q

how will lung sounds when volume is up

A

crackles or wheezes

186
Q

What can skin tell you about kidneys

A

-Bruising and bleeding - low H&H
-Tenting - shows dehydration
-Dry itchy skin
-Uremic frost - uric acid deposits in skin if not excreted

187
Q

CVA tenderness

A

back pain
can indicate infection
*check temp

188
Q

thrill

A

palpable pulsation of AV fistula or graft

189
Q

bruit

A

a functional AV fistula or graft has a a bruit on auscultation

190
Q

if you don’t hear a bruit or feel a thrill

A

AV fistula has clotted off = medical emergency

191
Q

What Review Of Systems questions are important for kidney fxn?

A

Urine output
Abdominal pain
n/v
Back pain
Rashes, itching
Lower extremity edema
SOB
Fever

192
Q

if urine is cloudy, what is that a sign of

A

infection

193
Q

if urine is clear/colorless, what is that a sign of

A

diuretics

194
Q

what should not be in urine

A

Proteinuria, blood, WBC, LE, Nitrites, casts, or glucose

195
Q

if UA is + for WBC, nitrite, leukesterase, what does that indicate

A

UTI
can empirically start antibiotics

196
Q

what will hyperkalemia look like on EKG

A

T wave will be higher than QRS

197
Q

how to tx hyperkalemia

A

Tx: IV D50 then regular insulin
Tx: calcium gluconate, sodium polystyrene sulfonate (Kayexalate)
Tx: dialysis

198
Q

Chvostek’s sign

A

hypocalcemia

199
Q

Trousseau’s sign

A

hypocalcemia, hypomagnesimia, and metabolic alkalosis

200
Q

what is a sign of hyponatremia

A

look for neuro disturbance can be anything from lethargy to seizure to coma, the lower it is < 135, < 120 is very bad, <116 is probably having major neuro disturbance-confusion, seizures

201
Q

normal cr level

A

0.6-1.2 mg/dl

202
Q

normal bun level

A

8-20 mg/dl

203
Q

when will BUN increase out of proportion to Cr

A

If patient is volume depleted, dehydrated or internal bleeding

204
Q

azotemia

A

BUN/Cr are both elevated

205
Q

KUB XR

A

kidney, ureter, bladder
can see stones, size of kidneys and hydronephrosis

206
Q

kidney radiology options

A

KUB XR
CT abdomen/pelvis
MRI
pyelogram
renal or renal artery US
kidney biopsy

207
Q

what will renal US show

A

Best for renal artery stenosis
What happens to RAAS in renal artery stenosis → messes with BP, harder to control
Can see obstructions in systems

208
Q

what do you want to check for after kidney biopsy

A

bleeding

209
Q

AKI

A

Abrupt or rapid decline in renal filtration function - seen w/ decreased GFR
Cr will double with 50% decrease in GFR

210
Q

risk factors for AKI

A

Older adults
Diabetics
Chronic kidney dysfunction
Chronic heart and liver disease

211
Q

causes of prerenal AKI

A

-Decreased CO → decreased perfusion to kidneys
-Hypovolemia
-Shock states
-Excessive diuresis (meds or hyperglycemia)

212
Q

how to tx prerenal AKI

A

Treat underlying cause
IVF, pressers, inotropes
Can be reversible with early intervention

213
Q

what is a sign of a AKI in older adults

A

change in mental status

214
Q

cause of intrarenal/intrinsic AKI

A

d/t acute damage of the glomeruli, renal parenchyma
-ATN (acute tubular necrosis)
Ischemic, Toxic (aka contrast dye, some antibiotics), Most common
-AIN (acute interstitial nephritis)
-GN (glomerulonephritis)
-Prolonged hypoperfusion
-Rhabdomyolysis
-Malignant HTN
-Kidney transplant rejection
-Infections

215
Q

s/s of intrarenal AKI

A

Hematuria, lower extremity edema, HTN if glomerular issue

216
Q

intrarenal/intrinsic AKI tx

A

Stop nephrotoxic meds
Hydrate
Treat underlying chronic diseases

217
Q

post renal AKI causes

A

d/t damage / obstruction along the urinary tract system - obstruction of flow from collecting ducts to external urethral orifice

Causes:
Cellular debris
Kidney stone
Tumor
Prostate enlargement
Trauma to the urinary tract
Renal vein thrombosis

218
Q

how to tx post renal AKI

A

remove obstruction, foley to empty bladder

219
Q

incidence of intrarenal/intrinsic AKIs

A

up to 40% of all AKI cases

220
Q

incidence of prerenal AKIs

A

As many of 21% of inpatient AKI

221
Q

incidence of post renal AKI

A

Lowest incidence of all AKI cases - 10%

222
Q

what is the most common cause of renal failure

A

acute tubular necrosis

223
Q

causes of ATN

A

Nephrotoxic drugs
-Damage to epithelial layer
-Antibiotics
-Contrast media
-Heavy metals
-Environmental chemicals

Ischemic origin
-Basement membrane origin
-Hypovolemia
-Decreased CO
-Systemic vasodilation
-DIC
-Renal vasoconstriction

224
Q

nephrotoxins

A

NSAIDs
Lithium
Benadryl, doxylamine
Acyclovir
Aminoglycosides
Amphotericin
Quinolones
Rifampin
Sulfonamides
Vancomycin
Antiretrovirals
Cyclosporine, tacrolimus
ACEs/ARBs
Chemotherapeutics
Contrast dye
Loop/thiazide diuretics

225
Q

what GFR indicates CKD

A

GFR < 60 for 3 months or greater

226
Q

Glomerulosclerosis

A

scarring of the filtering part of the kidneys (glomerulus)
Can be d/t diabetic nephropathy or hypertensive nephrosclerosis

227
Q

risks for CKD (5)

A

DM
Age
HTN
AKI
High cholesterol

228
Q

is CKD reversible?

A

no - pregressive and irrreversible

229
Q

how to tx CKD

A

Monitor labs
Avoid nephrotoxic drugs
Encourage PO hydration
ACE and ARB is renal protective in early disease
Mange comorbid conditions

230
Q

prognosis of CKD

A

CKD is a comorbid condition and increases in hospital morbidity and mortality rates
May progress to ESRD if left untreated

231
Q

what GFR indicates renal failure

A

GFR < 15 on dialysis

232
Q

AEIOU: emergent need for RRT

A

A - intractable acidosis
Ph < 7.2 or 7.3
E - electrolyte imbalance (hyperkalemia) and not responding to kalexylate or IV insulin
I - intoxicants (methanol ethylene glycol, Li, aspirin)
O - intractable fluid overload
U - uremic symptoms (nausea, seizure, pericarditis, bleeding)

233
Q

AV fistula

A

surgical anastomosis of an artery and a vein

234
Q

AV graft

A

created by inserting a prosthetic graft between an artery and vein, typically in the nondominant arm.
*not preferred, doesn’t last as long as fistula

235
Q

AE of hemodialysis

A

hypotension

236
Q

if patient is hypotensive during or after hemodialysis, what should the nurse do

A

stop dialysis, check vitals, call provider

237
Q

Hemodialysis Teaching & Complications

A

Cannot miss a dialysis treatment
Signs of infection
Hemorrhage from dialysis access
Aneurysm or pseudoaneurysm of access
Hypotension/hypertension from fluid imbalance
Thrombosis of dialysis access

238
Q

signs of peritonitis and tx

A

Cloudy drainage
Low grade temp
Abdominal pain
Tx: broad spectrum antibiotics

239
Q

what does retained dialysate indicate and what should you do?

A

Should drain equal or more than put in to dwell

Check tubing, reposition patient, lower the drainage bag, assess for s/s of fluid overload, fullness, or discomfort

240
Q

what is CCRT

A

continuous renal replacement therapy
Reserved for patients too unstable for HD
Hemodynamically unstable patients
Continuous slow filtration

241
Q

AE of CRRT

A

hypotension
hypothermia

242
Q

does HD or CRRT remove more blood

A

HD

243
Q

what does Blood streaked sputum indicate

A

carcinoma of the lungs

244
Q

what must be done when you change vent settings

A

draw ABGs within 20-30 minutes

245
Q

3 signs of o2 toxicity

A

collapsing of alveoli
seizures
disorientation

246
Q

aspiration can increase risk of which 2 resp illnesses

A

VAP (pneumonia) and ARDS

247
Q

how to decrease risk of aspiration (4)

A

OG tube
Head elevation > 30
Suction
Cuff pressure - 20-24 mm Hg

248
Q

4 criteria for ARDs

A

timing (w/i 1 week of known insult or worsening of respiratory symptoms)
chest imaging
origin of edema
oxygenation

249
Q

3 pathophys hallmarks of ARDS

A

Change in lung vascular tissue
Increased lung edema
Impaired gas exchange

250
Q

VAP bundle

A

-Oral care q4h
-HOB 30-45 degrees
-GI prophylaxis w/ PPI
-DVT prophylaxis w/ lovenox (40 ml sq daily = preventative)
-OOB
-Alcohol free mouthwash, teeth brushing, frequent oral suctioning

251
Q

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this?

A

The lung may have re-expanded or there is a kink in the system

252
Q

How many RR do you start someone with on a vent?

A

10-12 breaths/minute

253
Q

Functions of kidneys

A

Filtration & excretion
Electrolyte, fluid, acid/base balance
BP regulation
RBC production stimulation
Regulate calcium reabsorption in the bone

254
Q

s/s of tension pneumo

A

hypotension, hypoxia, breath sounds absent on affected side

Complex (3 decks)

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